Koshtha

The word ‘koshtha’ literally means enclosure or gut. Over the past decade, the concept of gut has revolutionized the health and wellness industry. The state of gut and its flora in every aspect of life, their impact on health and disease, interaction with the other parts of the body and external stimuli have been areas of interest in current research. Ayurveda has appreciated the role of gut in all the domains; conceptual, diagnostical and therapeutical. The multidimensional term ‘Koshtha’ has been used to denote the gut in Ayurveda. It has been comprehended as an organ, a collection of organs or a system, a channel, a disease pathway, and a therapeutic target. In the present article, the contributions of Ayurveda in each of these realms have been explored.

Contributors

Section/Chapter/topic	Sharira / Koshtha (The concept of gut in Ayurveda)
Authors	Karthik K.P.1
Reviewers	Basisht G.2
Editor	Deole Y.S. 3
Affiliations	1 Department of Kaumarabhritya, A.I.I.A., New Delhi, India 2 Rheumatologist, Orlando, Florida, U.S.A. 3 Department of Kayachikitsa, G.J. Patel Institute of Ayurvedic Studies and Research, Anand, India
Correspondence email	kpkarthik131@gmail.com, carakasamhita@gmail.com
Date of first publication:	May 08, 2022
DOI	under process

The anatomical and physiological extent

Anatomy of koshtha

The meaning of the word ‘Koshtha’ is ‘enclosure’. In Ayurveda, koshtha denotes the following anatomical ranges:

• Stomach to large intestines (amashaya to pakvashaya).[A.Hr.Sutra Sthana 12/46]
• Mouth to rectum (asya to payu).[Gayadasa commentary on Su.Sa.Nidana Sthana 7/6]
• Site (sthana) of collection of undigested food (ama), digestive fire (agni), digested food (pakva), urine (mutra), blood (rakta), and the organs, heart (hridaya), caecum (unduka), and lungs (phupphusa).[Su.Sa.Chikitsa Sthana 2/12-13]
• The term koshtha is also used to refer to duodenum (grahani), which is the pivot of digestion.[Su.Sa.Nidana Sthana 7/6]
• It is considered as a separate pathological terrain (rogamarga), serving as a stratum for its own unique set of diseases.

Fifteen organs have been enunciated as parts of koshtha: umbilicus (nabhi), heart (hridaya), pancreas (kloma), liver (yakrit), spleen (pleeha), kidneys (vrkkau), bladder (vasti), sigmoid colon (purishadhara), stomach (amashaya), cecum (pakvashaya), rectum (uttaraguda), anus (adharaguda), small intestine (kshudrantra), large intestine (sthulantra), and omentum (vapavahana). [Cha.Sa. Sharira Sthana 7/10]

Embryology

Koshtha consists mainly of smooth organs like stomach and intestines that are inherited from mother. [Cha.Sa.Sharira Sthana 3/6] Tilburg et.al., analyzed 308 irritable bowel syndrome (IBS) patients along with 102 healthy controls and 36 inflammatory bowel disease patients of Caucasian traits for maternal inheritance of IBS. 17.5% of the participants had a probable maternal inheritance and the maternal polymorphism 16519T that is seen associated with multiple other functional disorders. This was significantly associated with the maternally inherited IBS. As per Ayurvedic embryology, the precursor of gut is grossly seen in the fetus from the third month [Cha.Sa.Sharira Sthana 4/11] and attains full maturity by the seventh month. [Su.Sa.Sharira Sthana 3/30] The development of gut as per the western embryology starts from third week of intrauterine life and attains near-adult level functioning by 32 weeks.

Physiology

Koshtha is the important site for digestion. All the three doshas and their subtypes play pivotal role in maintaining the physiology of koshtha. The prana vayu (a type of vata) propels the timely administered food to the koshtha. The bodhaka kapha (a type of kapha) in oral cavity senses the taste of food. The kledaka kapha moistens the food and subjects it to digestion. Further, pachaka pitta and samana vayu lead the role in division into essence (saara) and waste (kitta). Samana vayu is important in breaking down the moistened food into small particles for easy digestion by pachaka pitta. Further, the wastes of food are expelled by apana vayu. The essence is circulated by vyana vayu. Hence, the proper functioning of all three are necessary to maintain the equilibrium in the koshtha. In the transient stages of digestion (avasthapaka) the dosha are nourished in their respective abodes. Kapha, Pitta, and Vata in amashaya (upper gastrointestinal tract with stomach), pachyamanashaya (small intestine) and pakvashaya (large intestine) respectively. These parts of koshtha are primary seats of the corresponding dosha.

Grahani (lower part of stomach and duodenum) and agni (factors responsible for digestion and metabolism) are the most important structural and functional components of koshtha respectively. Grahani holds undigested food till the completion of digestion. It is the part of koshtha that forms the substratum for agni. The nature of grahani is crucial in deciding the nature of koshtha. When grahani is unable to retain the food till proper digestion or when agni is so weak that it is unable to facilitate proper digestion, the result is improperly formed metabolites or ama.

Types of koshtha

There are basically three types of koshtha:

1. Hard (krura), predominant with vata dosha and in vata prakriti individuals

2. Soft (mridu), predominant with pitta dosha and in pitta prakriti individuals

3. Medium or intermediate (madhya) predominant with kapha dosha and in kapha prakriti individuals. It is also seen in the individuals with equilibrium state of dosha in prakriti.

Assessment of koshtha

The dominant dosha plays key role in functions of koshtha. The absorption due to dryness (ruksha) property of vata dosha leads to hard bowel. The slow movement is bowel is due to heaviness (guru), steadiness (sthira), slowness (manda) properties of kapha dosha. The fast movement in bowel is due to stimulating (sara), sharply acting (tikshna) and fluid (drava) properties of pitta dosha. The dosha exert their influence over grahani. Obstruction and stagnation are observed in hard bowels (krura koshtha); whereas the fluidity is the dominating property in soft bowels (mridu koshtha). [Chakrapani commentary on Cha.Sa.Sutra Sthana 13/65-69]

The consistency of fecal matter is the primary tool for assessment of koshtha. In the context of oleation (snehana), the fecal consistency is parameter to assess oleation. In subjects who have been properly oleated, the feces are well-formed, evacuated in a smooth, unctuous, unobstructed manner and without stickiness. Whereas in insufficiently oleated subjects, fecal matter is dry and hard (pellet-like). In over-oleated cases, the fecal matter is poorly formed (resulting in sticky feces).[Cha.Sa.Sutra Sthana 13/57-59]

Pathways of diseases in koshtha

Koshtha is one of the disease pathways. It plays vital role in pathogenesis of following diseases: fever (jwara), diarrhea (atisara), vomiting (chhardi), sluggish bowel (alasaka), acute non-infectious gastroenteritis (visuchika), cough (kasa), bronchial asthma (shwasa), hiccups (hikka), abdominal distension (anaha), ascites (udara), splenomegaly (pleeha), internal variants of erysipelas (visarpa), edema (shotha), abdominal lumps (gulma), hemorrhoids (arsha), and abscesses (vidradhi). [Cha.Sa.Sutra Sthana 11/49] Certain diseases are observed more in specific types of koshtha. Udavarta (diseases due to improper or reverse movement of vata dosha) is a complication of hemorrhoids (arsha). In subjects with vata-predominant koshtha, the condition may develop without hemorrhoids (arsha). [A.Hr.Nidana Sthana 7/52]

Poor appetite (kshudha-mandya), indigestion (ajirna) and poor digested matter (ama) are the basic pathological entities related to the koshtha.

The first two stages among six stages of pathogenesis (shat-kriya kala) i.e. the accumulative stage (sanchaya) and the provocative stage (prakopa) are confined to koshtha. The former is characterized by accumulation of dosha in their sites and the latter by excess aggravation of dosha. In case of gut, the obstructed bowels leading to pain and abnormal movement of vata, acid reflux, thirst, burning sensation, aversion to food and heartburn can be observed in these stages. The third stage characterized by overflow and migration of doshas (prasara) shows signs indicating the involvement of koshtha like abdominal distension, burning sensation, anorexia, indigestion, and vomiting.[Su.Sa.Sutra Sthana 21/18-32]

Factors influencing gut

Gut is a highly dynamic system characterized by interaction with both intrinsic and extrinsic factors. Among the extrinsic factors, food, regimen, region, and season, and among the internal factors, the physical constitution, age, and psyche are the most crucial ones. All these factors directly or indirectly influence the digestion and metabolism (agni), both at the gut level and at the tissue level. All these effects culminate at the endpoint called ‘ojas’ or ‘bala’ that is the product of the total metabolic activities happening in living body.[Su.Sa.Sutra Sthana 15/19] The baseline nature of the gut is decided by the physical constitution of the individual. The grahani of a vata-dominant individual is also vata-dominant. Hence the digestive pattern becomes irregular. When the dominance is of pitta dosha, digestive pattern is strong or fast (tikshna). In case of dominance of kapha dosha, the digestive pattern is slow (manda). [Cha.Sa.Vimana Sthana 6/18] A study conducted to identify the gut microbe diversity among rural population of western India revealed signature microbes that showed prakriti-specific distribution patterns despite the dominance of firmicutes and Bacteroidetes.

Causes of impairment of agni and koshtha

Agni is impaired by inadequate food intake, indigestion, overeating, irregular eating habits, consumption of unhabituated, heavy, cold, dry, stale food, improper administration of bio-purificatory therapies, emaciation due to diseases, regional and climatic differences, suppression of urges. These are some of the primary causes of diminution of agni and the cascade of further adverse events in koshtha. [Cha.Sa.Chikitsa Sthana 15/41-44]

Even if the appropriate food has been ingested in appropriate amounts, if the subject is going through excessive stress, grief, fear, anger, improper diurnal cycle, then the digestion is prone to impairment. [Cha.Sa.Vimana Sthana 2/9] Gut interacts with brain via metabolic, endocrine, immune, and humoral mechanisms. Hence, gut health and mood, cognition and mental health operate in tandem.

Therapeutic implications of koshtha

The objective of identification of koshtha are:

i. Diagnosis of the stage of disease (avastha)

ii. Decision of modality, drug, vehicle, and dosage

iii. Prognosis and assessment of therapeutic response

Diagnosis of stage of diseases

The stages of the diseases are based on multiple parameters. One of them is either the state of saama (associated with ama) or niraama (not associated with ama). Obstruction of channels, diminution of bala, heaviness, improper activity of vata, languor, indigestion, expectoration, difficulty in expelling waste matter, anorexia and tiredness are the cardinal features of saama state. The opposite features indicate niraama state.

Other important stages of diseases are subclinical or latent or dormant (lina dosha avastha) and clinical or manifested phase (vyakta dosha avastha). In former phase, the dosha stay dormant in the koshtha or in the circulatory channels. They manifest clinical features in favorable season, environment, region, etc. This leads to clinical phase. This stage is important to know, especially in allergy and other autoimmune pathologies, which exhibit seasonal flare-ups. [Su.Sa.Sutra Sthana 21/30], [A.Hr.Sutra Sthana 13/19]

The aggravated state when the dosha are ready to get expelled out (utklishta) is important state for purification therapies. The other state is when the dosha are not ready to get expelled out (anutklishta) state. This forms another dyad of disease stages. The former notes “vitiated and inclined to expulsion” and the latter its opposite.[Chakrapani commentary on Cha.Sa.Chikitsa Sthana 3/146] mobile or unstable (chala) and stable (sthira) states also share similar meanings.

The primary objective of understanding koshtha is the administration of diet, medicines, and therapeutic procedures. [A.Hr.Sutra Sthana 18/15] In general, the guideline for quantity of food that is healthy for everyone has been recommended based on his or her appetite and the capacity of koshtha. The time for food intake is decided based on symptoms indicating digestion of previous meal. The ideal mealtime is when the bowel and bladder has been evacuated, the chest is clear, the doshas are optimum, the belching does not reflect any undigested food, sequentially followed by hunger, vata is in its normal direction, when the agni is well kindled, the senses are intact and open to perception, and lightness is perceived in the body. [A.Hr.Sutra Sthana 8/55]

In therapeutic purification procedures (panchakarma), the dosha are eliminated only when they are located or brought into koshtha. This is observed by the signs like fullness and distension of abdomen after oleation and sudation.[Cha.Sa.Sutra Sthana 15/11] Koshtha also plays a major role in deciding the dosage of medicines. Soft bowels (mridu koshtha) are easy to oleate and evacuate.[A.Hr.Sutra Sthana 18/35] These individuals usually attain the expected oleation by three days and purgated using mild laxatives like milk, jaggery, buttermilk, juices of sugarcane, grapes, and decoctions like that of Triphala (combination of Terminalia chebula, terminalia bellirica and Phyllanthus emblica). The person with hard bowels takes about seven days to oleate and are also very difficult to purgate.[Cha.Sa.Sutra Sthana 13/65-69] This is the reason why mild forms of oleation mixed with food and drinks (vicharana) are indicated in soft bowel individuals. [Cha.Sa.Sutra Sthana 13/82] Medications like oils, marrow, etc. are advised in hard bowel individuals. Some other specific indications with respect to koshtha include that of oil in gut infested with worms (krimi koshtha), and muscle fats (vasa) in gut pains (koshtha ruja).

Sudation (swedana) is indicated mainly in hard bowel individuals (krura koshtha), especially in abdominal distension. It is not recommended in diseases arising due to pitta dosha with soft bowels (mridu koshtha). [Cha.Sa.Sutra Sthana 14/16,21] In koshtha, when vata afflicts the stomach (amashaya), initially dry sudation is to be done followed by unctuous sudation. When kapha dosha afflicts the large intestine (pakvashaya), the reverse order is to be followed. [Cha.Sa.Sutra Sthana 14/9]

Several pharmacological actions mentioned in Ayurveda revolve mainly around koshtha and its components. The actions that are specifically in relation with gut are: appetite stimulant (dipana), digestive stimulant (pachana), the digestion and propelling forward (anulomana), the action of expelling the adhered waste materials without digesting them (sramsana), doing the same function by liquifying (rechana), and by breaking the food items (bhedana).[Sha.Sa.Prathama Khanda/Chapter 4]

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